In January 2007, Mary Harney, Minister for Health & Children established the Commission on Patient Safety and Quality Assurance ("the Commission") and instructed it, among other tasks, "to develop clear and practical recommendations which would ensure the safety of patients".
In July 2008, the Commission completed its report entitled Building a Culture of Patient Safety . The report was published in August 2008 and approved by Government in January 2009. In her foreword to the report, chairperson Dr. Deirdre Madden states ... "When such adverse events occur there must be a system in place that ensures that all those affected are informed and cared for, and that there is analysis and learning from the error to try and prevent the recurrence of such an event."
Dr. Madden further recorded the objective of the Commission, namely, "to make recommendations for organisational, regulatory and educational reform which will create a culture of patient safety for our health system".
On 27th January 2009, Government approved the Commission's report and the Minister for Health & Children authorised the setting up of a Steering Group with a remit to drive the implementation of all the recommendations of the Commission's report, as effectively and efficiently as possible.
One of the key recommendations of the report was the development and support of a culture of open disclosure to patients and their next-of-kin, with the appropriate consent, when an adverse event results in harm to a patient.
The patients charter "You and Your Health Service" also states that patients in the HSE can expect "open and appropriate communication throughout their care, especially when plans change or if something goes wrong".
Open Disclosure National Pilot Project
The HSE, in conjunction with the State Claims Agency, piloted an open disclosure programme for two years in two acute hospitals, the Mater Misericordiae University Hospital, Dublin and Cork University Hospital. The aim of the project was the creation and support of an "open" approach in relation to the management of patients and their families/support persons following an adverse event and to develop a standardised system in relation to the management of open disclosure across all health and social care services. The pilot was completed in October 2010.
Launch of the National Documents November 2013:
On 12th November 2013 the HSE and State Claims Agency launched, following a wide national consultation process, a national policy and national guidelines on open disclosure with supporting documents which include a patient information leaflet, a staff support booklet and a staff briefing guide. The learning from (a)the work undertaken with the pilot sites and (b)an extensive research of best practice in open disclosure from other countries who have had open disclosure programmes in place for some time (Australia, Canada, United States of America and UK), was utilised in the developed of these national documents.
Significant work in now ongoing across all health and social care services in relation to the roll out of the national open disclosure policy and guidelines
For further details on the above please contact:
Open Disclosure. National Lead for the HSE
HSE Quality Improvement Division
Open Disclosure: National Lead. State Claims Agency
Ms Ann Duffy
Clinical Risk Advisor
State Claims Agency
Clinical Indemnity Scheme
Lower Grand Canal Street